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Lumbar punctures (LPs) are painful for children, and analgesia is recommended by academic societies. However, less than one-third of pediatric emergency physicians (EPs) adhere to recommendations. We assessed the willingness to provide analgesia among pediatric and general EPs and explored patient and provider-specific barriers.
We surveyed physicians in the Pediatric Emergency Research Canada (PERC) or Canadian Association of Emergency Physicians (CAEP) databases from May 1 to August 1, 2016, regarding hypothetical scenarios for a 3-week-old infant, a 3-year-old child, and a 16-year-old child requiring an LP. The primary outcome was the willingness to provide analgesia. Secondary outcomes included the type of analgesia, reasons for withholding analgesia, and their perceived competence performing LPs.
For a 3-week old infant, 123/144 (85.4%) pediatric EPs and 231/262 (88.2%) general EPs reported a willingness to provide analgesia. In contrast, the willingness to provide analgesia was almost universal for a 16-year-old (144/144 [100%] of pediatric EPs and 261/262 [99.6%] of general EPs) and a 3-year-old (142/144 [98.6%] of pediatric EPs and 256/262 [97.7%] of general EPs). For an infant, the most common barrier cited by pediatric EPs was the perception that it produced additional discomfort (13/21, 61.9%). The same reason was cited by general EPs (12/31, 38.7%), along with unfamiliarity surrounding analgesic options (13/31, 41.9%).
Compared to a preschool child and adolescent, the willingness to provide analgesia for an LP in a young infant is suboptimal among pediatric and general EPs. Misconceptions and the lack of awareness of analgesic options should be targets for practice-changing strategies.
Over 80% of children experience compromise in functioning following a fracture. Digital media may improve caregiver knowledge of managing fracture pain at home.
To determine whether an educational video was superior to an interactive web-based module (WBM) and verbal instructions, the standard of care (SOC).
This randomized trial included caregivers of children 0-17 years presenting to the emergency department (ED) with non-operative fractures. Primary outcome was the gain score (pre-post intervention) on a 21-item questionnaire testing knowledge surrounding pain recognition and management for children with fractures. Secondary outcomes included survey of caregiver confidence in managing pain (five-item Likert scale), number of days with difficulty sleeping, before return to a normal diet, and work/school missed.
We analyzed 311 participants (WBM 99; video 108; SOC 104) with a mean (SD) child age of 9.6 (4.2) years, of which 125/311 (40.2%) were female. The video (delta=2.3, 95% CI: 1.3, 3.3; p<0.001) and WBM (delta=1.6; 95% CI: 0.5, 2.6; p=0.002) groups had significantly greater gain scores than the SOC group. The mean video gain score was not significantly greater than WBM (delta=0.7; 95% CI: -0.3, 1.8; p=0.25). There were no significant differences in caregiver confidence (p=0.4), number of absent school days (p=0.43), nights with difficulty sleeping (p=0.94), days before return to a normal diet (p=0.07), or workdays missed (p=0.95).
A web-based module and online video are superior to verbal instructions for improving caregiver knowledge on management of children’s fracture pain without improvement in functional outcomes
We explored caregiver perspectives on their children’s pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children’s pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction.
This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009–2011.
Most caregivers were female (n=77, 79%) and were the child’s mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70–80) and mean score at discharge was 39 mm (95% CI: 32–46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child’s pain at ED discharge as severe were less likely to be satisfied than those who rated their child’s pain as mild or moderate (p=0.034).
Despite continued pain upon discharge, most caregivers report being satisfied with their child’s pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.
Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children’s MSK pain, both in the ED and postdischarge.
We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care.
A total of 543 medical records were reviewed (n 5 468 pediatric ED, n 5 75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving analgesics in the ED, 59% (126 of 214) received ibuprofen. Pain scores were recorded for 6% of patients. At discharge, ibuprofen was recommended to 47% and codeine-containing compounds to 21% of children. The average time from triage to first analgesic in the ED was 121 6 84 minutes.
Documentation of the assessment and management of children’s pain in the ED is poor, and pain management appears to be suboptimal. When provided, ibuprofen is the most common analgesic used for children with MSK pain. Pediatric patients with MSK pain do not receive timely medication, and interventions must be developed to improve the ‘‘door to analgesia’’ time for children in pain.
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